Transgender therapies for teens: a fine balance

Q: “Should young teens expressing a desire for gender reassignment be given hormone therapy while still in their early teens in light of the fact that the therapy will have lifelong irreversible impacts on their bodily (and perhaps cognitive) development?”

A: This question is complex and challenging and likely provokes very different initial reactions. Indeed, there are a range of possible responses available to these requests, from the strictly social (changing legal gender, as is proposed for children in Norway) to intensely medical (gender reassignment surgery).

Without further details about particular individuals and their context, this is difficult to answer in the abstract. At root, though, in these cases we are asking about how to provide the best possible care for such an individual within the constraints established by our health care and social systems.

One of the central principles in health care is respect for autonomy, which focuses on capacity, or patients’ ability to make health decisions for themselves.

In Nova Scotia, capacity is not determined by age or education, but by the ability to understand information relevant to a decision and the consequences that follow from this decision.

With young teens, questions about capacity are often raised as we try to find the best balance between recognizing a teen’s (developing) capacity to decide and society’s interest in protecting teens if they are not actually capable.

Health care also focuses on the possible harms that may result from treating or not treating an individual and seeks to minimize unnecessary harms as best we can.

Possible harms extend beyond the physical. For example, in this case, harms range from physical effects of drugs to the psychological harms of appearing socially as the unwanted gender to the risks of surgery.

These harms must be weighed against each other, but it is not clear which harms are least desirable. In fact, no decision in this case, including doing nothing, avoids all possibility of harm.

When dealing with children and teens, there may be concern that they are mistaken about their true gender.

While certain harms may best be avoided by initiating therapy with puberty blockers, these drugs must be administered before the onset of puberty to be most effective.

The possible harms related to any permanent effects of these drugs and/or side effects might be outweighed by the benefits for children and adolescents who identify as transgender and continue to do so. The concern, though, is that if they stop identifying as transgender, then the harms from puberty blockers or cross-gender hormone therapy will not be outweighed by the benefits of living in accordance with one’s gender identity. Further, treatment options that are more readily physiologically reversible are often less effective in creating the appearance of the desired gender, increasing the risk of psychological harm.

It is also important to recognize the role of context in decision-making — in this case, a society with a history of discrimination against transgender individuals and which remains, to varying degrees, transphobic. This history includes treating requests for gender reassignment with suspicion and subjecting adult trans-people to more stringent requirements to access gender reassignment surgery than others encounter when seeking, for example, plastic surgery.

These problematic attitudes are potentially exacerbated when the patients are children and adolescents, who often experience paternalism (which is in some cases justified). This social justice perspective raises questions as to whether we should take into account how long any particular client has identified as transgender in determining the appropriate response to their request for gender reassignment.

In working through requests like this, we often turn to evidence for additional guidance. However, in this case, it can be argued that long-term evidence around the effects of cross-gender hormone therapy is lacking. As such, there is clinical uncertainty regarding both responses to treatment and long-term risks. This uncertainty adds to the ethical uncertainty described above about which values should be given priority or how they should be balanced (e.g., respect for autonomy, social justice, and minimizing harms).

There is concern with these types of requests about getting it “wrong,” such that any actual harms are retroactively seen as unnecessary.

It is true that some degree of error or “second-guessing” is inevitable because these decisions are made in conditions of both clinical and ethical uncertainty.

With complex cases, it is important to carefully consider all of the available information at the point of decision but also to acknowledge the possibility of making a choice that falls short of the ideal outcome — while still working to increase the odds of achieving that ideal.

In ethics, we sometimes talk about the goal being not the right answer but a more-right answer. In this case, as in many others, a more-right answer will be one that reflects the most up-to-date evidence, respects the ability of children and adolescents to make choices, and minimizes the likelihood and degree of physical and psychological harms in both the long and short term.